Multimodality Imaging of Malignant Cardiovascular …...D E F Ao MPA MPA LM Ao LA LA RA LCC RCA RCA...
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1/3 https://e-jcvi.org A 14-year-old girl with unremarkable medical history was brought to our hospital owing to a brief episode of a sudden loss of consciousness during the cheerleading practice without preceding chest pain or palpitation. Upon arrival, she was oriented and cooperative. The initial rhythm on electrocardiogram was sinus tachycardia with nonspecific ST-segment depression in lead II, III and aVF, which suddenly turned to ventricular tachycardia (Figure 1A) followed by ventricular fibrillation causing cardiac arrest. She was defibrillated immediately with the return of spontaneous circulation in less than 3 minutes. A transthoracic echocardiogram showed normal leſt ventricular systolic function without wall motion abnormality. The aortic cusps appeared normal. The patient subsequently underwent cardiovascular magnetic resonance (CMR) to evaluate structural heart disease and myocardial ischemia. Notably, the coronal view of cine image demonstrated an abnormal tubular structure interposing between the aortic root and main pulmonary artery (arrow, Figure 1B, Movie 1). Shot axis view of adenosine stress perfusion image revealed a large area of inducible perfusion defect at anteroseptal, anterior and lateral walls, in the distribution of leſt main artery (LM) territory (arrows, Figure 1C). Based on all CMR findings, the anomalous origin of leſt coronary artery causing myocardial ischemia was suspected. The coronary computed tomography angiography demonstrated the origin of LM artery arising from right coronary cusp (RCC), coursing between the aortic root and pulmonary artery (Figure 1D and E). Pressure effect from the aorta and pulmonary artery to LM caused acute angle at the ostium (asterisk, Figure 1D) resulting in luminal narrowing. These confirmed the diagnosis of the inter- arterial type of anomalous LM arising from RCC caused malignant arrhythmia, hence the coronary angiography was deemed unnecessary in order to avoid further radiation exposure. Intraoperative findings revealed the right coronary artery normally originated from RCC while the LM abnormally arose from RCC (arrows, Figure 1F). She underwent the relocation of LM to leſt coronary cusp with uneventful postoperative follow-up. J Cardiovasc Imaging. 2020 Jul;28(3):e36 https://doi.org/10.4250/jcvi.2020.0007 pISSN 2586-7210·eISSN 2586-7296 Images in Cardiovascular Disease Received: Jan 24, 2020 Revised: Mar 7, 2020 Accepted: Mar 26, 2020 Address for Correspondence: Pairoj Chattranukulchai, MD Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, 1873 Rama IV Rd, Pathum Wan, Bangkok 10330, Thailand. E-mail: [email protected] Copyright © 2020 Korean Society of Echocardiography This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https:// creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. ORCID iDs Yongkasem Vorasettakarnkij https://orcid.org/0000-0003-0932-731X Pairoj Chattranukulchai https://orcid.org/0000-0001-6153-8398 Conflict of Interest The authors have no financial conflicts of interest. Weerapat Kositanurit, MD 1 , Manasawee Vassara, MD 2 , Yongkasem Vorasettakarnkij , MD 3 , Monravee Tumkosit, MD 4 , Vichai Benjacholamas, MD 5 , and Pairoj Chattranukulchai , MD 2 1 Department of Physiology, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand 2 Division of Cardiovascular Medicine, Department of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand 3 Division of Hospital and Ambulatory Medicine, Department of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand 4 Department of Radiology, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand 5 Division of Cardiothoracic Surgery, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand Multimodality Imaging of Malignant Course of Anomalous Left Main Coronary Artery: A Cause of Sudden Cardiac Arrest Provisional Provisional
Transcript of Multimodality Imaging of Malignant Cardiovascular …...D E F Ao MPA MPA LM Ao LA LA RA LCC RCA RCA...
1/3https://e-jcvi.org
A 14-year-old girl with unremarkable medical history was brought to our hospital owing to a brief episode of a sudden loss of consciousness during the cheerleading practice without preceding chest pain or palpitation. Upon arrival, she was oriented and cooperative. The initial rhythm on electrocardiogram was sinus tachycardia with nonspecific ST-segment depression in lead II, III and aVF, which suddenly turned to ventricular tachycardia (Figure 1A) followed by ventricular fibrillation causing cardiac arrest. She was defibrillated immediately with the return of spontaneous circulation in less than 3 minutes. A transthoracic echocardiogram showed normal left ventricular systolic function without wall motion abnormality. The aortic cusps appeared normal. The patient subsequently underwent cardiovascular magnetic resonance (CMR) to evaluate structural heart disease and myocardial ischemia. Notably, the coronal view of cine image demonstrated an abnormal tubular structure interposing between the aortic root and main pulmonary artery (arrow, Figure 1B, Movie 1). Shot axis view of adenosine stress perfusion image revealed a large area of inducible perfusion defect at anteroseptal, anterior and lateral walls, in the distribution of left main artery (LM) territory (arrows, Figure 1C). Based on all CMR findings, the anomalous origin of left coronary artery causing myocardial ischemia was suspected. The coronary computed tomography angiography demonstrated the origin of LM artery arising from right coronary cusp (RCC), coursing between the aortic root and pulmonary artery (Figure 1D and E). Pressure effect from the aorta and pulmonary artery to LM caused acute angle at the ostium (asterisk, Figure 1D) resulting in luminal narrowing. These confirmed the diagnosis of the inter-arterial type of anomalous LM arising from RCC caused malignant arrhythmia, hence the coronary angiography was deemed unnecessary in order to avoid further radiation exposure. Intraoperative findings revealed the right coronary artery normally originated from RCC while the LM abnormally arose from RCC (arrows, Figure 1F). She underwent the relocation of LM to left coronary cusp with uneventful postoperative follow-up.
J Cardiovasc Imaging. 2020 Jul;28(3):e36https://doi.org/10.4250/jcvi.2020.0007pISSN 2586-7210·eISSN 2586-7296
Images in Cardiovascular Disease
Received: Jan 24, 2020Revised: Mar 7, 2020Accepted: Mar 26, 2020
Address for Correspondence: Pairoj Chattranukulchai, MDDivision of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, 1873 Rama IV Rd, Pathum Wan, Bangkok 10330, Thailand.E-mail: [email protected]
Copyright © 2020 Korean Society of EchocardiographyThis is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
ORCID iDsYongkasem Vorasettakarnkij https://orcid.org/0000-0003-0932-731XPairoj Chattranukulchai https://orcid.org/0000-0001-6153-8398
Conflict of InterestThe authors have no financial conflicts of interest.
Weerapat Kositanurit, MD1, Manasawee Vassara, MD2, Yongkasem Vorasettakarnkij , MD3, Monravee Tumkosit, MD4, Vichai Benjacholamas, MD5, and Pairoj Chattranukulchai , MD2
1 Department of Physiology, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
2 Division of Cardiovascular Medicine, Department of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
3 Division of Hospital and Ambulatory Medicine, Department of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
4 Department of Radiology, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
5 Division of Cardiothoracic Surgery, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
Multimodality Imaging of Malignant Course of Anomalous Left Main Coronary Artery: A Cause of Sudden Cardiac Arrest
Provisional
Provisional
Inter-arterial type is the most common form of an anomalous coronary artery from opposite sinus that associates with sudden cardiac death in adolescence.1)2) This case highlights an important role of multimodality imaging by providing a complete anatomic description and functional assessment before contemplating the surgical strategy.
SUPPLEMENTARY MATERIAL
Movie 1The coronal view of cine cardiovascular magnetic resonance image demonstrate an abnormal tubular structure interposing between the great vessels.
Click here to view
2/3https://e-jcvi.org https://doi.org/10.4250/jcvi.2020.0007
Imaging of Anomalous Left Main Coronary Artery
A B C
D E F
Ao MPA
MPA
LM
Ao
LA
LA
RA
LCC
RCARCA
RCA
LAD
LMNCC
LCC
RCC MPA
LCXRCC
*
Figure 1. (A) The initial electrocardiogram revealed sinus rhythm, which suddenly turned to ventricular tachycardia. (B) The coronal view of cine cardiovascular magnetic resonance image demonstrated an abnormal tubular structure (arrow) interposing between the aortic root and MPA. (C) Shot axis view of adenosine stress perfusion image revealed a large area of inducible perfusion defect (arrows) in the distribution of LM territory. (D) The coronary computed tomography angiography showed the origin of LM arising from RCC with acute angle at the ostium (asterisk) coursing between the Ao and pulmonary artery (E). (F) Intraoperative finding revealed the LM abnormally arose from RCC. Ao: aorta, LA: left atrium, LAD: left anterior descending artery, LCC: left coronary cusp, LCX: left circumflex artery, LM: left main coronary artery, MPA: main pulmonary artery, NCC: non-coronary cusp, RA: right atrium, RCA: right coronary artery, RCC: right coronary cusp. Dashed line represents the cutaway MPA.Provisional
Provisional
REFERENCES
1. Cheezum MK, Ghoshhajra B, Bittencourt MS, et al. Anomalous origin of the coronary artery arising from the opposite sinus: prevalence and outcomes in patients undergoing coronary CTA. Eur Heart J Cardiovasc Imaging 2017;18:224-35. PUBMED | CROSSREF
2. Finocchiaro G, Behr ER, Tanzarella G, et al. Anomalous coronary artery origin and sudden cardiac death: clinical and pathological insights from a national pathology registry. JACC Clin Electrophysiol 2019;5:516-22. PUBMED | CROSSREF
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Imaging of Anomalous Left Main Coronary Artery
Provisional
Provisional
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